Health Insurance - Access to Nonparticipating Providers - Referrals, Additional Assistance, and Coverage
SB902 expands and makes permanent Maryland’s rules governing access to out-of-network, or nonparticipating, specialists when a carrier’s provider panel cannot provide timely or appropriate care. The bill repeals the sunset on certain 2022 provisions and updates the referral process for insurers, nonprofit health service plans, and health maintenance organizations so that members can obtain referrals to specialists or nonphysician specialists outside the network when the carrier lacks the needed expertise or cannot provide reasonable access. It also adds explicit protections for mental health and substance use disorder care, including a requirement that carriers provide additional assistance when a member cannot secure such services through the standard referral process.
The bill further limits carrier utilization management for these referrals. It prohibits prior authorization requirements for scheduling, reimbursing, or continuing an established treatment plan with a nonparticipating specialist in the covered circumstances, and it bars utilization review beyond what would apply if the service were delivered in-network. For mental health and substance use disorder services, the bill requires that cost-sharing be no greater than in-network for the duration of the treatment plan. It also directs the Maryland Health Care Commission to establish a reimbursement formula for nonparticipating providers delivering these services by January 1, 2026, after holding public meetings with carriers, providers, consumers, and other interested parties.
In practical terms, SB902 amends Maryland Insurance Article § 15-830 and extends the 2022 access-to-specialist framework beyond its prior expiration date. It affects health insurers, nonprofit health service plans, HMOs, members seeking specialty care, and nonparticipating physicians and nonphysician specialists, especially behavioral health providers. The bill applies to policies and plans issued, delivered, or renewed on or after January 1, 2026, while the act itself takes effect in stages beginning June 1, 2025, with the substantive insurance changes effective January 1, 2026.
The overall sentiment around the bill appears strongly supportive. The recorded votes were unanimous in both chambers, with the Senate passing the bill 47-0 and the House passing it 133-0. That voting history suggests broad bipartisan agreement that the access protections should continue and be strengthened, particularly for mental health and substance use disorder care.
There is little evidence of overt opposition in the available record, but the bill does contain a few likely pressure points. Carriers may be concerned about limits on prior authorization, reduced utilization review, and the requirement to cover out-of-network mental health and substance use disorder treatment at in-network cost-sharing levels. Providers and consumer advocates, by contrast, are likely to support the bill’s emphasis on timely access, additional assistance, and a reimbursement formula for nonparticipating behavioral health providers. The Maryland Health Care Commission’s rate-setting role may also be a point of interest because it will shape how the new coverage rules operate in practice.
SB902 amends Maryland Insurance Article § 15-830 to permanently extend and expand the state’s referral and coverage rules for nonparticipating specialists. It removes the sunset from earlier 2022 legislation, adds new assistance requirements for mental health and substance use disorder referrals, restricts prior authorization and extra utilization review for qualifying out-of-network care, and requires the Maryland Health Care Commission to establish a reimbursement formula for certain nonparticipating providers. The bill affects health insurers, nonprofit health service plans, HMOs, members, and nonparticipating specialists, with special emphasis on behavioral health access.
The bill appears to have enjoyed broad, bipartisan support. It passed the Senate 47-0 and the House 133-0, indicating consensus that the existing access-to-specialist protections should be continued and strengthened. The unanimous votes suggest the measure was viewed as a consumer-access and behavioral health coverage bill rather than a controversial policy change.
No formal opposition is reflected in the available committee or floor record, but the main policy tension is between consumer access and carrier utilization controls. Health plans may object to limits on prior authorization, reduced utilization review, and mandatory in-network-equivalent cost-sharing for out-of-network mental health and substance use disorder treatment. Supporters are likely to emphasize improved access, continuity of care, and stronger protections when networks are inadequate, especially for behavioral health services. The reimbursement formula to be set by the Maryland Health Care Commission may also be a point of concern for carriers and providers because it will determine payment levels for nonparticipating care.